Global Community to Accelerate Action Against Tobacco Smoking

Washington — In a special session of the U.N. General Assembly September 19-20, the world community is expected to agree on an “action-oriented” plan for combating noncommunicable diseases (NCD). According to a State Department official, the plan is expected to have an emphasis on healthy lifestyles as the key step in prevention of these disorders, which include cardiovascular disease, respiratory disease, cancer and diabetes.
At a Washington panel discussion September 12, Ann Blackwood summarized four months of negotiations over the document, which is expected to be formally adopted next week at the conclusion of the U.N. General Assembly’s Special Session on Noncommunicable Diseases. Blackwood is the director of health programs for the Bureau of International Organization Affairs within the U.S. Department of State and a participant in the discussions.
“International collaboration is highlighted,” she told the audience of health and development specialists attending the Washington event, hosted by the Center for Global Development. The transfer of technology from developed to developing countries, and the inclusion of NCD awareness and prevention at all stages of development projects, are other activities the communiqué will recommend, Blackwood said.
Noncommunicable diseases killed more than 39 million people in 2008, according to the World Health Organization (WHO), which is 63 percent of all deaths occurring worldwide that year. About 80 percent of the NCD deaths occurred in low- and middle-income nations, a statistic “dispelling the myth that such conditions are mainly a problem of affluent societies,” according to a WHO report on the rising NCD death toll issued in April 2011.
The U.N. session is intended to raise awareness on the significance of NCDs as a factor in global health and to mobilize collaborative, international action to better prevent, treat and understand these diseases.
One key objective for U.S. participants in the discussions of the document that will be presented to the U.N. for approval was to emphasize “the idea of health in all policies,” according to a representative from the U.S. Department of Health and Human Services (HHS).
NCDs are such a wide-reaching problem, Holly Wong said, that all government officials should be thinking about how the activities of their agencies might promote or prevent noncommunicable diseases. “Trying to include agencies in finance, transportation, agriculture, education, energy and all the other sectors in this discussion has been an important way of looking at risks and looking at how we can promote healthy choices.”
Wong said HHS will be asking the health industry, business and society at large for ideas to reduce the incidence and damage of NCDs.
HHS was effective in negotiating the inclusion of strong language on tobacco control, Wong said, including accelerated implementation of the Framework Convention on Tobacco Control, adopted by the World Health Assembly in 2003, and provisions advocating greater taxation on tobacco as a means to reduce tobacco use.
The U.S. Centers for Disease Control and Prevention has already established a solid record of helping other governments reduce tobacco use. Patricia Simone with the Center for Global Health said the Global Tobacco Control program has supported tobacco use surveillance in more than 100 countries. The work collects data that demonstrates tobacco use as a risk factor for other serious diseases, and it also builds local skills in health data collection and analysis that will support future efforts to assess a population’s health habits.
The international focus on the damage caused by noncommunicable diseases dates back to a study conducted several years ago, involving several influential bodies including the World Bank and the Bill and Melinda Gates Foundation.
The study found that a nation’s investments in the prevention of NCDs would produce the greatest benefit in prolonging life expectancy, reducing disability and extending life productivity for its citizens.
By Charlene Porter

Time for action in New York

A major opportunity to advance global health is in danger of being lost. On Sept 19—20, heads of states and governments will gather in New York, NY, USA, at the UN High-Level Meeting on Non-communicable Diseases (NCDs) to approve a political statement on responding to the global NCD crisis. These diseases, principally cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, are responsible for two-thirds of the 57 million deaths worldwide each year, with four of five NCD deaths occurring in low-income and middle-income countries; at least half these deaths are readily preventable. Until now they have been neglected by countries, development agencies, and funders.
A bold and comprehensive statement from the UN High-Level Meeting will stimulate a global response commensurate with the burden of NCDs. The negotiations on the draft political statement stalled at the beginning of August because of major differences between the leading negotiating countries. The UN Resolution specifying the details of the meeting called for “an action-oriented document”; the co-facilitators are committed to producing a strong outcome statement. Lamentably, so far, the negotiations have produced a weak statement that will do little to protect vulnerable populations from the ravages of NCDs.
The preliminary paragraphs of the draft statement make many excellent points—for example, on the challenge to development posed by NCDs—and this is an important step forward. However, when it comes to proposed actions, the statement lacks vision and ambition. Crucially, it does not include a bold goal for reducing preventable mortality from NCDs—for example, the WHO goal of a 25% reduction in national mortality rates by 2025 based on 2010 rates. One of the key lessons from the Millennium Development Goals and the global response to HIV/AIDS has been the importance of time-bound goals and targets. An ambitious but achievable global NCD goal will drive change and allow for accountability on progress.
There is insufficient emphasis in the draft on the affordable, available, cost-effective, priority population-wide interventions, several of which will be cost-saving even in the short term. The two top priorities—tobacco control and salt reduction—will enable countries to reduce mortality quickly at very low cost, and achieve much of the mortality reduction goal. Nor does the draft include associated targets to assess progress in controlling these major causes of NCDs. A key measure for making progress—increased taxes on tobacco and alcohol—will not only improve health but also raise the required revenue to fund prevention and treatment programmes. The Framework Convention on Tobacco Control is a major achievement, yet the negotiations seek to downplay its implementation rather than accelerate it. The draft language on improving the availability of affordable cost-effective medicines, especially for people at high risk of cardiovascular diseases and other NCDs, is still vague.

Finally, there is little attention in the draft to the need for a flexible and efficient NCD partnership to follow through on the commitments and the appropriate accountability mechanisms. There are important precedents in both these areas from maternal and child health: the Countdown to 2015 Initiative and the proposed Accountability Commission. An independent NCD partnership, in close association with WHO, other major global institutions, and the NCD Alliance, is required to synthesise the available information on effective interventions, disseminate this evidence, monitor progress and, above all, advocate for more rapid progress. Accountability for the global and national commitments to NCD prevention, as agreed at the UN High-Level Meeting, could be incorporated into the responsibility of the Accountability Commission for Maternal and Child Health with regular reporting to the Secretary General of the UN.
The next few weeks will be crucial in determining the final political statement from the UN High-Level Meeting. The Lancet is deeply committed to the prevention of NCDs as part of its support for global health. We urge all concerned countries, institutions, and individuals to make their voices heard by the negotiators in New York and by their ministers, building on the advocacy shown by the NCD Alliance. This is too good an opportunity for improving global health to be missed. We will be judged harshly, and rightly so, if we fail to make a major advance in addressing this neglected aspect of the health of people worldwide.
The Lancet

Antitobacco programs underfunded, WHO says

Tobacco control programs remain “seriously underfunded” worldwide, despite increases in revenue-generating tobacco taxes, the World Health Organization (WHO) reveals in its third report on the global tobacco epidemic.

The big picture of the epidemic remains largely “unchanged,” the WHO says, in part because of a lack of political will to finance antitobacco initiatives, although some countries have made progress to implement new control measures since 2009 (

Governments collect nearly US$133 billion in tobacco tax revenue each year, but spend less than US$1 billion on tobacco control, the WHO Report on the Global Tobacco Epidemic, 2011 reveals (

It’s a disparity that Armando Peruga, program manager of the WHO’s Tobacco Free Initiative, calls “basically ridiculous” and one that is particularly acute in low-and middle-income countries.

Tobacco tax revenues are 4304 times higher than tobacco control expenditures in low-income countries, compared to 1339 times higher in middle-income countries and 124 times higher in the wealthiest nations.

It’s not for a lack of funds, either, the report argues, as “most countries have sufficient financial resources available to expand and strengthen [national tobacco control programs].”

Since 2008, 11 countries and one territory have increased taxes on tobacco products to the WHO-recommended minimum of 75% of the products’ retail prices. At present, 26 countries and one territory in total, representing about 8% of the world’s population, have set levies on tobacco at or above that minimum. A further 154 countries have set taxes on tobacco products at 25%–75% of their retail prices.

“There’s still a belief out there that the tobacco epidemic is a problem of the rich countries or the rich people in poorer countries, and that’s not true,” says Peruga, explaining that some 80% of tobacco-related deaths occur in low-and middle-income countries.

“There’s a link between tobacco use and poverty that we need to make apparent for countries, particularly low-income countries, to really take on the epidemic as a social problem and economic problem, not just a health problem,” he says.

It costs governments “almost nothing” to make workplaces, restaurants, bars and other indoor public places smoke-free, to enforce bans on tobacco advertising and sponsorship, or to require health warnings on tobacco products, the WHO argues — but only a minority of countries have implemented such measures to date.

“We still have not reached a critical mass of countries doing all they can and should, but we’re seeing good progress in a handful of countries that are setting the pace for others,” Peruga says. “We’re beginning to see decreases in the prevalence of tobacco use, for example, in countries where we’ve not seen them in the past, such as Uruguay, India, Turkey and other middle-income countries.”

Mandating graphic health warnings on tobacco products has been one of the most widely implemented interventions to date. More than 100 countries, representing over half of the global population, now have some kind of policy requiring warning labels on tobacco products. However, those policies only meet best practices in 19 countries, representing just 15% of the world’s people.

The success of other interventions has been likewise tempered, according to the report.

Ninety-eight countries, representing about half of the global population, have legislated certain public places as smoke-free environments, but only 11% of the world’s people are actually covered by comprehensive smoke-free policies.

Comprehensive national health care services supporting smoking cessation are available in only 19 countries, representing 14% of the world’s population.

Meanwhile, bans on tobacco advertising and sponsorship have the potential to decrease tobacco consumption by up to 16%, according to WHO estimates, but only 19 countries, constituting 6% of the world’s population, have introduced such strictures.

Tobacco-related illness kills nearly 6 million people each year, more than 600 000 of whom are nonsmokers exposed to second-hand smoke. With tobacco consumption on the rise globally, the WHO warns that the annual death toll could climb to more than 8 million by 2030.

“We are pleased that more and more people are being adequately warned about the dangers of tobacco use,” WHO Assistant Director-General for Non-communicable Diseases and Mental Health Dr. Ala Alwan said in a press release ( “At the same time, we can’t be satisfied that the majority of countries are doing nothing or not enough.”

By Lauren Vogel

No Progress On Nitrosamine Levels In U.S. Cigarettes

For more than 30 years, scientists have known how to reduce cancer-causing chemicals called nitrosamines in cigarettes. But cigarettestoday’s cigarettes have similar levels of these chemicals as did cigarettes made three decades ago, according to research presented this week at a Division of Chemical Toxicology symposium at the American Chemical Society national meeting in Denver.
The processes that turn green tobacco leaves into cigarettes can convert nicotine and related alkaloids into two nitrosamines, N-nitrosonornicotine and 4-methyl-N-nitrosamino-1-(3-pyridyl)-1-butanone. These compounds aren’t the only cancer-causing chemicals in cigarettes, but strong evidence links both to cancer in smokers. Outside the U.S., many cigarette manufacturers use alternative tobacco-processing methods that produce significantly lower levels of these chemicals. In 1999, two major U.S. cigarette companies stated that they planned to reduce levels of nitrosamines in their cigarettes.
Irina Stepanov, a research associate in Stephen Hecht’s lab at the University of Minnesota, Twin Cities, wondered if the companies had kept their promise. In April 2010, she and her colleagues bought 17 brands of U.S. cigarettes, measured levels of the two nitrosamines in the tobacco and in the cigarettes’ smoke, and then compared those amounts to reports for cigarettes produced in years past.
When they averaged nitrosamine levels across the brands, the researchers found no significant difference from reported data on cigarettes made in 1979 and 1995 (Tob. Control, DOI: 10.1136/tc.2010.042192). When they looked at the eight brands introduced since 1999, just one had lower nitrosamine levels than the 1979 amounts. The researchers say that the brand’s lighter nitrosamine load is likely due to the type of tobacco plant it uses.
“Our data indicate that cigarette companies haven’t made any meaningful attempts to reduce nitrosamines in U.S. cigarettes over the past three decades, despite having the knowledge and tools to do so,” Stepanov says. She suggests that government regulation may be the only way to make cigarette companies reduce nitrosamine levels. Such regulation is possible under the Family Smoking Prevention and Tobacco Control Act, which grants the Food & Drug Administration the authority to regulate harmful substances in tobacco products.
Paul Hollenberg, a pharmacologist at the University of Michigan, Ann Arbor, says the study reminds him of the late 1970s and early 1980s, when scientists detected nitrosamines in beer. “Public pressure led to changes in brewing practices that have basically eliminated nitrosamine carcinogens from beer in the U.S.,” he says. “I certainly hope the findings presented here today will have similar effects.”
Laura Cassiday
Chemical & Engineering News
ISSN 0009-2347
American Chemical Society

Smoking ban linked to reduction in heart attacks

COLUMBUS — Enactment of Ohio’s strict ban on smoking in indoor public places was immediately followed by a sharp decline in the number of apparent heart attacks, a state study released Thursday showed.
The Ohio Department of Health also said the nearly 5-year-old law does not appear to have adversely affected the bottom lines of bars and restaurants.
“Symptoms of heart-related disorders, diseases that are clear diagnoses of heart attacks, and public attitudes are all reinforcing that this was a good decision,” said Dr. Ted Wymyslo, state health director.
“We were the first state in the Midwest and the first tobacco-growing state to move forward with this type of ban,” he said. “I want to tell you, it was a wise thing to do.”
The studies released Thursday are the first in a series to be released in coming months as the state attempts to gauge the impact of the indoor public smoking law passed by voters in November 2006 and implemented the following May. A study examining asthma rates is under way.
With few exceptions, the law prohibits smoking in offices, bars, restaurants, clubs, sports arenas, and any other enclosed place that has employees or is frequented by the general public. Business owners must remove ash trays and post no-smoking signs or face fines that increase in severity with multiple offenses.
Even as court battles continue over the fairness of how the law has been enforced, the state has begun to go after the liquor licenses of bars and restaurants that refuse to pay fines levied for violations of the ban.
Although state researchers can’t definitively tie it to the indoor smoking ban, researchers noted that an examination of hospital discharge data showed a sudden and dramatic dip in the number of heart attack-related discharges from hospitals after the state began to enforce the law in May 2007. The hospital data did not indicate whether the heart attack victims were smokers.
“However, it really is kind of remarkable to see this kind of drop,” said David Bruckman, of the Cleveland Department of Public Health and Case Western Reserve University. “We don’t really know why that occurred. We have to assume that it is coincident to the introduction of the first few months of the ban.”
Cresha Auck, director of government relations for the Ohio Heart Association, said a reduction in the number of heart attacks should have been expected as cigarette smoke disappeared from places frequented by the public.
“The cardiovascular system is impacted from tobacco smoke exposure within 20 minutes, so that’s why you see the heart attack rates come down,” she said.
The state used sales tax collections from businesses that sell alcohol for on-site consumption to examine the economic impact of the ban. Bars, some restaurants, bowling alleys, and other businesses that serve alcohol fought passage of the ban, arguing that it would result in many of their smoking customers to stop visiting their businesses or at least spend less time there.
“There was no statistically significant change in sales that was associated with the Ohio Smoke-Free Workplace Act that has hurt either bars or restaurants,” said Elizabeth Klein, of Ohio State University’s College of Public Health. “These findings are consistent with studies that have been conducted in cities, counties, states, and countries where there are no significant effects associated with policies that restricted smoking in workplaces.”
Much of the time period examined by the state funds coincided with when Ohio was spending in the neighborhood of $40 million a year in tobacco-settlement funds to help smokers quit and discourage non-smokers, particularly youths, from taking up the habit. The program was all but halted a couple of years ago when Ohio disbanded the anti-smoking foundation and confiscated its funding for other purposes.
Shelly Kaiser, spokesman for the American Lung Association in Ohio, noted that the state saw an up-tick in smoking rates in 2010 for the first time since the ban took effect. An estimated 22.5 percent of Ohioans said they smoked last year, up from 20.3 percent the year before.
Ohio this year will spend $1 million on enforcement of the law, using one-time federal funds that won’t be available next year. Dr. Wymyslo had just partial success in convincing lawmakers this spring to appropriate smoking cessation funds. He was not armed at the time with the graphs and statistics he presented yesterday.
“The fact that we don’t have a lot of readily available funding at this point won’t stop us from moving forward,” he said. “What we’ve developed is a tobacco collaborative where we’ve joined forces with private employers and insurers to see if we can find other ways to fund our tobacco cessation activities.
“Do not believe that our commitment to tobacco cessation has gone down,” Dr. Wymyslo said. “It’s the number-one best known risk factor for chronic disease. It causes one in five deaths that happen in Ohio, currently 18,000 a year.”

World-first plain packaging for tobacco products becomes law in Australia

Legislation requiring tobacco products to be in plain packaging was passed by the House of Representatives last night. This is the first such measure in the world to become law.
We asked a roundtable of experts to respond to the news.
Colin McLeod, Associate Professor & Executive Director, The Australian Centre for Retail Studies at Monash University, looks at the possible impact of the legislation on the retail industry.
The whole issue of tobacco is a challenging one for the retail industry.
The passage of the plain packaging bill yesterday adds to the complexity and if the bill succeeds in achieving the objectives stated by Heath Minister Nicola Roxon, retail sales of tobacco will fall.
In many retail sectors tobacco sales still represent between a fifth and a third of sales revenue. While it’s legitimate to argue that retailers should have weaned themselves off their reliance on a product category that is under substantial threat from regulation and community attitudes, this has been difficult.
Part of the problem for retailers is that while volumes have fallen as the proportion of the population who smokes reduces, the drop has been largely offset by upward changes in the price of tobacco products.
While some of this has been due to price increases by retailers and wholesalers, it’s worth noting that about 65% of the cost of a packet of cigarettes is federal excise duty plus GST. Although in fairness to our Federal Government, this is at the lower end of comparable OECD countries.
The net effect is that tobacco products have maintained their financial significance to the retailer as a share of turnover.
The other major issue for retailers is that they are members of the communities that they serve, and they have to find a balance between understanding and responding to community attitudes and running a viable business.
Tobacco represents a unique case, as other product categories can develop alternative strategies – for example McDonald’s can introduce healthy meals or Mars can reduce the fat content of their products in response to community concerns about childhood obesity.
But there is no middle ground on tobacco, as can be seen from the response of public health experts to yesterday’s announcement – we can’t find a healthier way to smoke.
Mike Daube, Professor of Health Policy at Curtin University and Director of the Public Health Advocacy Institute, considers why Australia’s tobacco plain packaging legislation is important for public health.
First, it will help to reduce smoking in adults by encouraging them to quit, and in children by removing the tobacco industry’s last advertising vehicle.
It shows that a determined minister (Nicola Roxon) acting on expert advice and compelling evidence, supported by unanimous health and medical support, can face down massive (and massively misleading) advertising and public relations campaigns, as well as lobbying and legal campaigns by the world’s most lethal industry and its shadowy allies.
Despite some sadly misinformed speeches from a few oppposition politicians, all-party support for the plain packaging bill shows that Australian politicians can work together to reduce our largest preventable cause of death and disease.
But perhaps crucially, this is a precedent that, once set, will be followed over time by many other countries. The history of tobacco control shows that the domino theory justifies every tobacco executive’s worst nightmare.
Legislation (and other important measures, such as major mass media programs) are always fiercely opposed by tobacco interests; but when one country or state shows the art of the possible, the others follow.
The argument that “nobody else has done it” will no longer apply. Other countries and other governments will be encouraged by the Australian Government’s world-leading initiative, and will note that the tobacco industry’s credibility has fallen even further, aided by so many leaks and revelations about its deceptive tactics.
Public health campaigners will press for action, confident that they have all the ammunition they need, from research evidence to advocacy approaches.
The Australian tobacco industry is entirely controlled from London (British American Tobacco and Imperial Tobacco) and New York (Philip Morris). The global industry has poured tens of millions into opposing plain packaging here, partly because they know it will work, but above all because they are desperate to prevent measures like this from being introduced in other countries.
There is much yet to be done, but the tobacco wars are being won in Australia. Plain packaging serves as a beacon to the rest of the world, especially developing countries, where the new battlegrounds are forming and hundreds of millions of lives are at stake.
Professor Rob Moodie, the inaugural Chair of Global Health at The University of Melbourne discusses the possible impact of the law in global public health.
It’s well known that tobacco companies use packaging as a way of advertising and promoting their products, so this is a very significant legislation that strikes at the very heart of Big Tobacco.
And it’s clear from the reaction of tobacco companies that they’ve taken it seriously. Their willingness to invest in massive advertising campaigns and to vilify the health minister is evidence that this law will have an impact.
The passing of the Bill is particularly important as a prelude to the September High-level Meeting on Non-communicable Diseases in New York because it will help strengthen the global resolve to act against tobacco and its harms.
We should all remember that in the Reputation Institute’s 2009 Global Reputation Pulse Report, the tobacco industry comes last. It has repeatedly shown that it has very deep pockets and that it’s willing to threaten, sue and bully to get its own way.
The law is a very important leap forward because it starts to protect the public from what is a really dangerous product.
I’ve never had any doubts that tobacco should remain a legal product – it can now remain to be a legal product without being able to promote itself.
This move will give other countries encouragement to initiate public health measures that will help minimize tobacco’s harms for their populations.
Deborah Gleeson, Research Fellow in the School of Public Health and Human Biosciences at La Trobe University, examines what this means for the negotiations for the Trans Pacific Partnership Agreement.
Australia’s leadership in tobacco control must extend to trade agreements
Australia is taking a leadership role in global tobacco control. This leadership must also extend to trade agreements that threaten the success of tobacco control by enabling Big Tobacco to take legal action against governments.
The burden of premature death from tobacco use is disproportionately borne by low and middle income countries, many of which have yet to introduce effective tobacco control policies.
In many countries where smoking rates are high and economies are closely enmeshed with the tobacco industry, tobacco companies hold far more power than they do in Australia.
It is vitally important that the tobacco industry is not granted additional powers to take legal action to oppose tobacco control measures recommended by the World Health Organization.
The Trans Pacific Partnership Agreement currently being negotiated between Australia, the United States, New Zealand, Chile, Singapore, Brunei, Peru, Vietnam and Malaysia is one such trade agreement. Three more rounds of negotiations are planned for later this year and member countries are now tabling draft text and making their positions clear.
The United States Government is seeking investor state dispute settlement provisions in this agreement that would grant powers to foreign companies to sue governments directly in international courts over public health legislation. Philip Morris International has indicated that it would sue the Australian Government if such provisions were included in the agreement.
Australia’s position against these provisions is strong. The Government’s Trade Policy Statement released in April 2011 states it “will not accept provisions that limit its capacity to put health warnings or plain packaging requirements on tobacco products” (p. 14).
This is welcome news for public health advocates.
But Australia’s stance on the inclusion of these provisions for other members of the Trans Pacific Partnership is less clear. The provisions would make countries like Vietnam and Malaysia even more vulnerable to the bullying tactics of Big Tobacco.
Australia has indicated that it will not seek these clauses in its trade agreements with developing countries. To fully implement the policy, trade negotiators must actively reject efforts to include them in the regional agreement, and work with developing country members to strengthen their positions.
The next round of negotiations, in September, presents an ideal opportunity.
Australia must take its leadership role seriously and ensure that the investor state dispute settlement is kept out of the Trans Pacific Partnership Agreement. This will deal a big blow to the global bullying capacity of Big Tobacco.
Luke Nottage, Associate Professor in the Sydney Law School at The University of Sydney, discusses the possible impact of the legislation on bilateral investment treaty law and practice.
The plain packaging legislation passed the Australian Parliament stuck to the original proposal for implementation.
So Philip Morris Asia (PMA) is likely to commence investor-state arbitration (ISA) proceedings after expiry of the 3-month “cooling off” period under Art 10 of the 1993 Australia – Hong Kong bilateral investment treaty (calculated from notification of the dispute on 27 June).
The Gillard Government has closed off one avenue for settling this dispute by enacting legislation but delaying its implementation, to give more time for PMA and other companies to prepare for the new regime.
Even if the possibility of delaying implementation comes up in arbitral proceedings, perhaps due to arbitrators attempting to facilitate early settlement (‘Arb-med’), the Government will now find it politically difficult to backtrack in this respect.
Early and cost-effective settlement during arbitral proceedings will also become harder if the Government decides that it’s worth risking billions of dollars to compensate PMA in exchange for savings in many more billions spent annually on tobacco-related illnesses.
More cynically, the Gillard Government may be thinking that it will get votes in the short-term by coming down hard on tobacco companies with this legislation, without having to take much responsibility for a compensation payment if and when the tribunal reaches a final decision because that may take several years.
The recent escalation of the Gillard Government’s dispute with PMA is unfortunate for another reason. It will entrench the view in the April “Trade Policy Statement” that ISA should not be included in any future investment treaties.
This stance goes far beyond the Productivity Commission’s recommendation on ISA in its Inquiry Report last year, yet the Commission’s economic theory and evidence was already questionable.
Australia seems now to have thrown out the ISA baby with the bathwater. This has serious implications for economic integration initiatives particularly in the Asia-Pacific region, including ongoing FTA negotiations with Japan.
It’s a broader dimension often overlooked when people hear about PMA’s ISA claim related to the new legislation.
A longer version of Luke Nottage’s contribution can be found at on the “Japanese Law and the Asia-Pacific” blog.

Extreme negative anti-smoking ads can backfire

COLUMBIA, Mo. – Health communicators have long searched for the most effective ways to convince smokers to quit. Now, University of Missouri researchers have found that using a combination of disturbing images and threatening messages to prevent smoking is not effective and could potentially cause an unexpected reaction.
In a study recently published in the Journal of Media Psychology, Glenn Leshner, Paul Bolls and Kevin Wise, co-directors of the Psychological Research on Information and Media Effects (PRIME) Lab at the University of Missouri School of Journalism, found that showing viewers a combination of threatening and disgusting television public service announcements (PSAs) caused viewers to experience the beginnings of strong defensive reactions. The researchers found that when viewers saw the PSAs with both threatening and disgusting material, they tended to withdraw mental resources from processing the messages while simultaneously reducing the intensity of their emotional responses. Leshner says that these types of images could possibly have a “boomerang effect,” meaning the defensive reactions could be so strong that they cause viewers to stop processing the messages in the PSAs.
In their study, the researchers showed 49 participants anti-smoking television PSAs. Some PSAs included disgusting images and some did not. Further, some PSAs included an explicit health threat while others did not. The researchers monitored the participants’ emotional responses and how much attention they paid to both types of images through self-report questions as well as through sensors that measured heart rate and physiological negative emotional response from muscle activity above the eye socket on the brow.
The researchers found the PSAs which included either a threatening message or a disgusting image resulted in greater attention, better memory, and a heightened emotional response. However, PSAs that included both threatening and disgusting images caused participants to have defensive responses, where defensive reactions were so strong that the participants unconsciously limited the mental resources they allocated to processing the messages. They also had worse memories and a lower emotional responses when the threatening PSAs included disgusting images. Leshner says that when a disgusting image is included in a threatening PSA, the ad becomes too noxious for the viewer.
“We noticed in our collection of anti-tobacco public service announcements a number of ads that contained very disturbing images, such as cholesterol being squeezed from a human artery, a diseased lung, or a cancer-riddled tongue,” Leshner said. “Presumably, these messages are designed to scare people so that they don’t smoke. It appears that this strategy may backfire.”
Bolls says that the recent MU study shows that new FDA regulations requiring cigarette companies to include potentially threatening and disgusting images on cigarette packages may be ineffective at communicating the desired message that smoking is unhealthy.
“Simply trying to encourage smokers to quit by exposing them to combined threatening and disgusting visual images is not an effective way to change attitudes and behaviors,” Bolls said. “Effective communication is more complicated than simply showing a disgusting picture. That kind of communication will usually result in a defensive avoidance response where the smoker will try to avoid the disgusting images, not the cigarettes.
Bolls goes on to say that one of the major limitations of the new regulation is that the FDA is relying on smokers to take the disgusting images and make the cognitive leap that those images portray what they are doing to their bodies and that they should quit smoking to prevent those conditions.
“You can’t get that kind of message out explicitly just by putting a gross picture on a package of cigarettes; yet, that is the kind messaging that needs to take place to have a chance at changing smokers’ habits,” Bolls said. “You have to talk to smokers in a meaningful and encouraging way that outlines the consequences of smoking, but also have messages designed to minimize the defensive avoidance responses.”
By Nathan Hurst
[email protected]
University of Missouri-Columbia

Reason for Depression When Smokers Quit

Acute withdrawal from heavy smoking may increase levels of monoamine oxidase-A (MAO-A), consistent with observations of smoking quitdepressed mood during smoking cessation, results of a brain-imaging study suggest.
Levels of MAO-A in the prefrontal and anterior cingulate cortices increased by as much as 33% during withdrawal as compared with active smoking. Withdrawal-associated levels of MAO-A exceeded those of nonsmoking healthy controls by 25%.
The variations in MAO-A levels between smoking and withdrawal correlated with plasma levels of harman, a beta-carboline found in cigarette smoke, and also with severity of depression, investigators reported in the August issue of Archives of General Psychiatry.
“The increase in prefrontal and anterior cingulate cortex MAO-A binding and associated reduction in plasma harman level represent a novel, additional explanation for depressed mood during withdrawal from heavy cigarette smoking,” Ingrid Bacher, PhD, of the University of Toronto, and coauthors wrote in conclusion.
“This finding resolves a long-standing paradox regarding the association of cigarette smoking with depression and suicide, and argues for additional clinical trials on the effects of MAO-A inhibitors on quitting heavy cigarette smoking.”
Biological concepts related to smoking cessation have focused in large part on nicotine modulation of dopamine-releasing neurons. As applied to therapeutic interventions, the strategy has led to six-month abstinence rates of as much as 40%, the authors noted in the background information.
Cigarette smoke also affects other potential neural targets for smoking cessation, such as MAO-A. For example, a PET imaging study showed that smoking was associated with global reductions in MAO-A binding in smokers versus a control group of nonsmokers (Proc Natl Acad Sci USA 1996; 93: 14065-14069).
MAO-A binding in the prefrontal and anterior cingulate cortices has been implicated in regulation of affect. Additionally, a theoretical basis exists for MAO-A to influence mood during smoking withdrawal, the authors continued.
Many substances in cigarette smoking have a short half-life, including harman. Conceivably, rapid disappearance of the substances from plasma could lead to rapid elevation in MAO-A binding. Whether acute smoking withdrawal increases MAO-A binding has not been investigated previously.
To examine changes in MAO-A binding during smoking withdrawal, Bacher and colleagues recruited 24 otherwise healthy individuals with a history of moderate (15 to 24 cigarettes daily) or heavy (≥25 cigarettes daily) smoking and 24 healthy, nonsmoking controls.
The smoking group consisted of 12 moderate smokers and 12 heavy smokers.
MAO-A binding in the brain was assessed by means of PET with [11C]harmine. Participants in the control group underwent a single PET imaging study. The smokers underwent one imaging study during active smoking and a second study during acute withdrawal. For the withdrawal study, smokers stopped cigarette use eight hours before PET imaging.
Before PET imaging, investigators obtained plasma samples from participants to assess levels of several MAO-A binding substances, including harman. All participants were screened to rule out Axis I or Axis II disorders. Visual analogue scales were used to assess mood, anxiety, and energy at two-hour intervals beginning eight hours before PET imaging.
The primary finding was a significant increase in MAO-A density during withdrawal in the subgroup of heavy smokers. As compared with the active smoking phase, MAO-A increased by 23.7% in the prefrontal cingulate cortex and by 33.3% in the anterior cingulate cortex (P<0.001). The changes were not observed in moderate smokers during withdrawal.
MAO-A density was significantly higher during the withdrawal phase of the 12 heavy smokers as compared with the control group (P=0.004). The magnitude of the difference was 25.0% in the prefrontal cortex (P=0.001) and 25.6% in the anterior cortex (P=0.001).
Changes in plasma harman levels mirrored the PET-detected changes in MAO-A density (P=0.01). Significant correlations were observed for the prefrontal cingulate cortex (P=0.009) and the anterior cingulate cortex (P=0.02).
The VAS scores among heavy smokers also varied with the increases in MAO-A density, exhibiting a significant shift toward depression (P=0.006). Other VAS scores did not vary with MAO-A density.
By Charles Bankhead
MedPage Today

We’re off the cigarettes but still struggling with alcohol and drugs

WE’VE got the message about smoking, are refusing to change our risky drinking habits with the notable exception of teenagers and pregnant women, and our appetite for illicit drugs has risen in the past three years.
The mixed picture of drinking and drug use is revealed today in the Australian Institute of Health and Welfare’s National Drug Strategy Household Survey, which shows men are more likely to use legal or illegal drugs than women, except for pharmaceuticals, which are used equally.
The AIHW survey of 26,000 people reveals the proportion of people aged 14 and over smoking daily is 15.1 per cent, down from 16.6 per cent three years ago and 25 per cent in 1993. Of those 12-17, only 3.2 per cent of girls smoke daily and 1.8 per cent of boys.
“This . . . is encouraging, as tobacco smoking is the single most preventable cause of ill-health and death,” AIHW spokesman Brent Diverty said yesterday.
The biggest declines in daily smoking are among people in their early 20s to mid-40s, but for over-45s the proportion remained relatively stable, and for some age groups increased slightly.
Alcohol consumption at levels risking harm (more than two standard drinks a day) has remained constant at about one in five people since 2007, although the proportion aged 14 or older who consumed alcohol daily declined from 8.1 per cent in 2007 to 7.2 per cent last year.
In a sign the advertising campaign on the risks of alcohol for teenagers is working, a significant drop in teenage drinking has occurred. In 2007, 61.6 per cent of those 12-17 consumed alcohol at least once in the year, while last year the figure fell to 54.5 per cent.
More pregnant women are heeding the health message about alcohol, with 52 per cent abstaining from alcohol last year compared with 40 per cent in 2007.
The AIHW survey shows illicit drug use within the past 12 months rose from 13.4 per cent in 2007 to 14.7 per cent last year.
“There was an increase in the proportion of people who used cannabis, pharmaceuticals for non-medical purposes, cocaine and hallucinogens,” Mr Diverty said. “But for the first time in since 1995, ecstasy use declined between 2007 and 2010, from 3.5 per cent to 3 per cent.”
The impact of alcohol use on others worsened in the past three years, the AIHW survey shows, with the proportion of people reporting they were physically abused by a person under the influence of alcohol increasing from 4.5 per cent to 8.1 per cent.
Stephen Lunn

Cigarette Alternatives Threatening Anti-Smoking Progress

While indoor-smoking bans encourage smokers to quit, a variety of new, smokeless products threaten to keep them hooked, and to lure young people into nicotine addiction.
That’s the view of the American Cancer Society, the National Cancer Institute, and many researchers looking into the newest cigarette alternatives. These products include smokeless tobacco, dissolvable tobacco, and electronic cigarettes.
“Manufacturers are introducing a very convenient, widely available product delivering nicotine, which is incredibly addictive,” said Ware Kuschner, MD, Associate Professor of Pulmonary and Critical Care Medicine at Stanford University. “Do we want to unleash this to adolescents, to children?”
Manufacturers claim that their cigarette alternatives are made to satisfy adult smokers’ craving for nicotine when they can’t light up. Because these products produce no smoke, users can indulge at work, in restaurants and bars, at school, and other places smoking is banned.
Although the levels of tobacco-specific nitrosamines are lower than in cigarettes and the products contain the same amount of nicotine as in cigarettes or in some cases even less, they are far from harmless, health advocates warn, noting that too little is known about the newest products to judge their risk.
The most studied alternative is smokeless tobacco. A 2008 study by the World Health Organization showed that smokeless tobacco users have an 80% higher than average risk for oral cancer and a 60% higher risk for esophageal and pancreatic cancers. But the risk is still considerably lower than it is for lung cancer in cigarette smokers. The most common effects of smokeless tobacco are gum disease and benign oral lesions.
“Lifetime [smokeless-tobacco] users would probably have less risk for cancer, and certainly respiratory disease, than lifetime smokers,” said Mark Parascandola, PhD, MPH, an epidemiologist with the National Cancer Institute’s Tobacco Control Research Branch.
Thomas J. Glynn, PhD, Director of Cancer Science and Trends for the American Cancer Society, has a similar view: “There are no safe forms of tobacco,” he said, “but certainly less harmful forms.”
A study published earlier this year in the Journal of Agricultural and Food Chemistry (2011;59:2745–2751) suggests that dissolvable tobacco also has the potential to cause oral and gum problems, and a study of e-cigarettes by the FDA in 2009 found several samples with nitrosamines and other carcinogens.